Rushing from one home to another in Wadgaon village of Yavatmal in northern Maharashtra, health worker Babybai Fakira Shinde cannot afford to take a breather. Working to keep Covid-19 at bay, while caring for others, Babybai races between households to meet her job targets.

An Accredited Social Health Activist ~ or ASHA, an acronym that translates as “hope” in Hindi ~ is the Government’s recognised health worker who is usually the first port of call for any health-related demands in rural India, where healthcare facilities are scant and medical professionals can be hard to find. Babybai, 41, has spent over a decade in the 15-year-old all-female army of foot soldiers which is the sole health provider in many villages, with 1,000 to 1,500 people in each ASHA’s care.

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Over the years, she has overseen countless births, meticulously monitored the health of these newborn babies and strictly ensured immunization through door-to-door awareness campaigns. The personal relationships she built over the years have given her a good grasp of the medical histories of most of the 1,500 people assigned to her. “It’s all in here,” Babybai says, pointing to her head. The ASHA initiative was the result of the 2005 National Rural Health Mission for improving the health of vast swathes of rural India cut off from doctors, clinics and hospitals.

ASHAs were imagined as a dedicated roving band of community health workers to act as a stopgap in the porous health care system. They are responsible for activities like maintaining data, registering new pregnancies, births and death, referring disease cases, supporting health services through home visits, conducting first-aid, and immunisation, creating awareness about contraception and maternal-fetal wellbeing, monitoring key diseases like tuberculosis and malaria and participating in community health planning.

They also escort pregnant women to the nearest primary healthcare centres and help them in opening bank accounts for receiving a monthly allowance from the government. India features close to the bottom in international rankings in most health indices. The Covid-19 pandemic exposed the fundamental problems plaguing the healthcare system, be it physical infrastructure, manpower or health management. At least two-thirds of India’s 1.3 billion people depend on the public healthcare system, but the country has only 8.5 hospital beds and eight physicians per 10,000 people. Compare this with Japan and South Korea which have 120 and 130 beds per 10,000 people respectively.

As a result, many Indian communities, especially women and children, rely on ASHAs for primary healthcare. On account of the burgeoning costs of private healthcare and the inability of public healthcare to respond to the needs of the huge population, India’s remote villages have traditionally relied on indigenous health systems of basic care supported by community agents. Community health workers are greatly improving the lives of millions of people where doctors and nurses don’t go.

Community healthcare providers, like paramedics, are taught essential services such as maternal and child healthcare. The strategy is to move beyond doctors and nurses and shift down to lay people, peers and family. Any visitor to a village where these community healthcare models are the primary drivers of awareness will marvel at the ability of the ASHAs to connect with and explain things to women. Their lack of a degree is not a handicap, it is an advantage.

They understand how to reach the people who most need reaching out to Illiterate, vulnerable and poor village women. They know how they think and live because they are one of them. The efficacy of the ASHAs can be seen in the impact they have made on India’s healthcare indicators. Their efforts have contributed to a 59.9 per cent decline in maternal mortality and a 49.2 per cent decline in infant mortality. Under their aegis, immunisation rates for the country increased from 44 per cent to 62 per cent and institutional deliveries doubled from 39 per cent to 78 per cent. This example underscores that there is scope to develop frontline cadres in other sectors as well.

The water and agriculture sectors, in particular, would benefit significantly from the stronger involvement of frontline cadres. In an administrative unit, four to five ASHA workers report to one Auxiliary Nurse-Midwife (ANM). They go door-to-door in their signature pink saris educating people about maternal and child health, contraception, immunisation and sanitation, as well as enrolling them in health programmes and monitoring the results. Currently, India has approximately 9,00,000 ASHA workers and they perform several other duties that make their role peripatetic.

For the work that ASHAs do, they are paid an honorarium and performance-linked top-ups. A typical monthly honorarium is Rs 2,000-Rs 4,500 depending on which state they belong to. Over and above this honorarium, they receive small incentives for completing specific “recurring” tasks. They receive Rs 100 for vaccinating a child against measles, mumps and rubella, Rs 40 for reporting a child death, Rs 300 for accompanying a woman to a hospital for childbirth, Rs 600 for delivering a baby for a family living below the poverty line and Rs 1,000 for administering TB treatment over six-seven months. They are being paid an additional Rs 1,000 for Covid-19 interventions.

Be it heading up village maternal care or running vaccination drives, ASHA workers are a linchpin. But they face a number of challenges in performing their jobs, including insufficient training, high workloads, poor support for home visits, poor credibility in the community, difficulty addressing sensitive topics with families and little or no feedback about performance. They are treated like volunteers, not even entitled to minimum wages.

This model has been inspired by innovative experiments like that of SEARCH (the Society for Education, Action and Research in Community Health), in the district of Gadchiroli, and the Comprehensive Rural Health Project in the district of Jamkhed. The promoters of these innovations believe that sicknesses in rural areas could be prevented with clean water, proper waste-disposal systems and more diverse farming. They believe that they do not need experts. An array of women like village health workers is enough if they are properly trained and supported.

Both these local healthcare providers recruit ordinary women to take care of their village’s health. The health workers create awareness about handwashing, nutrition, breastfeeding and simple home remedies. The model is not without its share of critics. ASHAs receive outcome-based remuneration based on how many patients they serve and the specific targets they meet. Incentivized pay can be a powerful tool. Yet incentivized pay may encourage behaviour that doesn’t put the patient’s interests first. Specifically, India’s family planning policy provides ASHAs with targets for sterilization, a form of permanent birth control. Women who use this form of family planning are paid up to Rs 1000 to undertake the operation while ASHA workers are remunerated Rs 150 for each woman they bring to the health care centre or hospital. Those incentives explain why sterilization makes up the major modern contraceptive use in India.

Many ASHAs don’t offer other choices for women seeking family planning because there are no incentives for promoting them. Technology can enable India to leapfrog into an advanced healthcare system that fulfils the vision of the national health policy of promoting wellness, universal access and affordable care for all Indians.

The National Digital Health Mission (NDHM) seeks to enable this by bridging the existing gap among different stakeholders of the healthcare ecosystem through digital highways. Many ASHA workers are graduates and others are educated to at least Class 10. Basic training in technology along with access to tablets or smartphones can transform the ASHA worker into a Digital Health Agent to deliver healthcare solutions to the masses. There are however many challenges to this approach, involving digital literacy, connectivity challenges, smartphone access, internet penetration, etc. We can use it as an addition ~ not a replacement ~ to existing services.

While ASHA workers have the potential to play a wider role in rural healthcare their service conditions need to be improved. Even though the Code on Social Security, 2020 aims to include formal and informal sectors under a social safety net, it excludes several categories of workers, including ASHA and Anganwadi workers.

The Code on Wages, too, has left this constituency out of its coverage, depriving employees of a fixed minimum wage. ASHAs are identified more as facilitators for appropriate care and the community has fewer acceptances for their curative role. In future, the ASHAs could be leveraged intensively in diagnosing health conditions to promote a comprehensive community health management approach. The more capable among them could be trained to handle advanced problems.

This will be relevant for cost-effective elderly care and settings with increasing chronic disease burdens. The ASHA programme could motivate and empower local lay women on community health issues. The desire to gain social recognition, a sense of social responsibility and self-efficacy enhances the motivation of ASHAs. Linking their incentives directly with each activity ensures their performance.

The improvements in the healthcare delivery system might further enhance their motivation and enable them to gain the community’s trust. The management of ASHAs needs to change with adequate supportive supervision, skill and knowledge enhancement and enabling working conditions if we want them to become an effective grassroots cadre that is both resilient and impactful